Provider Demographics
NPI:1235298175
Name:MARTIN, PETER REED (LAC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:REED
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 SW MORRISON ST STE 907
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3105
Mailing Address - Country:US
Mailing Address - Phone:503-294-0162
Mailing Address - Fax:866-901-7829
Practice Address - Street 1:715 SW MORRISON ST STE 907
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3105
Practice Address - Country:US
Practice Address - Phone:503-294-0162
Practice Address - Fax:866-901-7829
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC 00199171100000X
ORLMT 883247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other